Hancock Park Rehabiliation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Hancock Park Rehabiliation and Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF686Jul 14, 2023

  Based on observation, record review, and interview, the facility failed to implement treatment interventions for a deep tissue injury (DTI- a pressure-related injury to subcutaneous tissues under intact skin), for one Resident (#58), out of a total of 27 sampled residents. Subsequently, the wound deteriorated. Findings include: Review of the facility's Skin Integrity Guidelines, dated 2019, indicated: *The interdisciplinary team will address problems, goals and interventions directed toward prevention of pressure ulcers and/or skin integrity concerns identified. Resident #58 was admitted to the facility in June 2022 with diagnoses including cancer and epilepsy. […]

• Actual harm, isolatedF688Jul 14, 2023

  Based on observation, record review, and interview, the facility failed to prevent a decline in range of motion causing the development of a contracture for one Resident (#16), out of a total sample of 27 residents. Findings include: Resident #16 was admitted to the facility in February 2019 and has diagnoses that included but were not limited to age-related osteoporosis, nutritional anemia, dementia, abnormalities of gait and mobility, insomnia, and unspecified protein-calorie malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 6/6/23, indicated Resident #15 scored a 3 out of 15 on the Brief Interview for Mental Status exam indicating a severe cognitive impairment and is dependent on staff for bed mobility, transfers, dressing, toilet use, hygiene, and bathing. […]

• Actual harm, isolatedF692Aug 17, 2021

  Based on observations, records reviewed, and interviews, the facility failed to ensure that timely interventions were identified and provided for one Resident (#54), based on the comprehensive assessment from a total sample of 24 residents. Specifically, the facility 1.) Failed to implement timely nutritional interventions to prevent further weight loss; 2.) Failed to provide necessary eating assistance; and 3.) Failed to monitor meal intakes. Findings include: 1. Resident #54 was admitted to the facility in December 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF880Dec 4, 2025

  Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed:1. For Resident #48, who was diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA), a bacterium that is resistant to several antibiotics, to ensure staff implemented precautions after entering and exiting a room identified as being on contact precautions, and2. To implement an infection control surveillance plan for identifying, tracking, monitoring and/or reporting of infections, communicable diseases and outbreaks among residents and staff.Findings include:1. […]

• No harm, potential for more than minimal, widespreadF680Aug 17, 2021

  Based on interviews and review of the Activity Director's personnel file, the facility failed to ensure the activity program was directed by a qualified activities professional. Findings include: On 8/17/21, review of the Activity Director's personnel file failed to indicate the Activity Director was certified as a qualified activities professional and had not completed a training course approved by the Commonwealth of Massachusetts. During an interview on 8/13/21 at 2:55 P.M., the Activity Director said she was hired for the position in March 2021. The Activity Director said when she was hired the plan was for her to take the training course through the National Certification Council for Activity Professionals, but she had not enrolled in the course yet, five months after being hired. […]